Medication Therapy Management Program
Available to our Cal MediConnect (CMC) line of business are Medication Therapy Management (MTM) services that include comprehensive medication reviews (CMR) conducted by a licensed pharmacist and targeted medication reviews (TMR).
Formerly, MedWiseRx provided these services. For 2022, the Navitus Clinical Engagement Center (CEC) provides MTM program services. Eligibility criteria for a member to receive these services in 2022 will include a minimum of three chronic diseases, a minimum of eight Part D medications, and an annual cost for covered Part D medications totaling $4,696 or more. CMS also expanded the MTM program eligibility criteria for 2022 to include members who are enrolled in our Drug Management Program (described below).
The Centers for Disease Control and Prevention (CDC) has endorsed MTM services, stating that "MTM has been shown to be effective for lowering systolic and diastolic blood pressure; lowering LDL cholesterol and other health indicators (e.g., glycosylated A1C, HbA1c); increasing patient knowledge; improving patient quality of life and medication adherence; and improving the safe and effective use of medications."1 In 2021, CMS required health plans to reach a Comprehensive Medication Review (CMR) completion rate of at least 89% to achieve a five-star rating, and a similar rate is expected for 2022.
Medication Adherence Program
As part of an ongoing effort to improve medication adherence for our CMC members, L.A. Care Health Plan has collaborated with Navitus CEC (our MTM vendor) to deliver Pharmacoadherence services to our members.
You may be receiving a letter or call for members under your care that have been identified with gaps based on medication refill history. Please discuss the information and ways to improve medication adherence with the member. Members are also eligible to receive 100-day supplies of all their chronic medications.
Drug Management Programs — Opioid Home Program/ Pharmacy Home Program
According to the U.S. Department of Health and Human Services, 1.6 million people had an opioid use disorder in 2019 and 70,630 people died from drug overdose that same year.2
In an attempt to curb the opioid epidemic, L.A. Care has implemented two drug management programs, the Pharmacy Home Program (PHP) and the Opioid Home Program (OHP). Currently, PHP targets L.A. Care Covered ™ and PASC-SEIU Homecare Workers Health Plan lines of business, and OHP targets the Cal MediConnect (CMC) line of business. On 1/1/2022, Medi-Cal was removed from our PHP program due to the Medi-Cal Rx carve out, as the state Medicaid agency will not be continuing opioid lock-in programs.
Both programs lock members into one designated provider and/or pharmacy for receiving opioids and benzodiazepines for 12 months, with an option to extend an additional 12 months depending on case management.
Currently, for a beneficiary to be eligible to enroll in OHP or PHP program, they must have an average MME ≥ 90 mg for any duration within the most recent 6 months and obtaining prescriptions for opioids or benzodiazepines from either a) 3 or more providers and 3 or more pharmacies OR b) 5 or more providers regardless of the number of pharmacies. CMC members will also be eligible for OHP if they have had a history of opioid-related overdose.
As of 1/1/2022, any beneficiary diagnosed with sickle cell disease will be excluded. Other exclusion criteria include (depending on the program) members receiving foster care, members with access or quality of care issues, members receiving hospice, palliative, or end-of-life care, residents of an LTC facility, or members being treated for active cancer-related pain.
If you have questions about the changes, please contact the L.A. Care Provider Solutions Center at 1.866.522.2736. You can call 24 hours a day, 7 days a week, including holidays.
1. Centers for Disease Control and Prevention. Updated August 27, 2021. Community pharmacists and medication therapy management. Centers for Disease Control and Prevention. Retrieved December 14, 2021, from https://www.cdc.gov/dhdsp/pubs/guides/best-practices/pharmacist-mtm.htm.
2. U.S. Department of Health and Human Services. Updated October 27, 2021. What is the U.S. opioid epidemic? HHS.gov. Retrieved December 10, 2021, from https://www.hhs.gov/opioids/about-the-epidemic/index.html.